CascadeGuide USAID-SMARTTA

w
HIV CASCADE TOOLKIT:

A USERS GUIDE
for constructing, presenting , interpreting

and using HIV cascades in Vietnam
2014
TABLE OF CONTENTS
HIV CASCADE TOOLKIT: A USERS GUIDE for constructing, presenting , interpreting and using HIV cascades in Vietnam
TABLE OF CONTENTS
ABBREVIATIONS 3
ACKNOWLEDGEMENTS 4
I. Overview and Purpose
Purpose of this document
II. Adaptation of the HIV CoPC Cascade in Vietnam 7

Common features of HIV cascades
Guiding Principles
Vietnams HIV CoPC cascade
10
III.
CoPC Cascade Metrics 13
1:1 rule
13
Numbers first
15
Data limitations
17
IV.
Building a CoPC cascade 18
Preparatory steps
18
Data collection guidance and considerations
19
Adjusting data
20
V.
Presenting a CoPC cascade 21
General presentation guidelines
21
Stacking cascade bars
22
Graphic presentation styles
24
VI.
Interpreting a CoPC cascade 26
Interpretation tips
26
VII. Supporting others to generate, present and use simple HIV CoPC cascades 27

Key resources
27
VIII. Summary 28
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Abbreviations
AIDS
ART
ARV
CDC
CoPC
D28
FSW
HIV
HTC
KP
LTFU
M&E
MMT
MSM
NGI
OPC
PEPFAR
PLHIV
PWID
TB
U.S.
VAAC
Acquired Immune Deficiency Syndrome

Antiretroviral Therapy
Antiretroviral
United States Centers for Disease Control and Prevention
Continuum of HIV Prevention to Care
Decision 28 (provides guidance on how to routinely report results of Vietnams HIV/AIDS program)
Female Sex Worker
Human Immunodeficiency Virus
HIV Testing and Counseling
Key Population
Loss To Follow Up
Monitoring and Evaluation
Methadone Maintenance Treatment
Men who have Sex with Men
Next Generation Indicators
Out Patient Clinic
The Presidents Emergency Plan for AIDS Relief
People Living with HIV
People Who Inject Drugs
Tuberculosis
The United States of America
Vietnam Authority of HIV/AIDS Control, Ministry of Health
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Acknowledgements
The U.S. Presidents Emergency Plan for AIDS Relief (PEPFAR) through
the United States Agency for International Development (USAID)
has provided financial support for development of the HIV Cascade
Toolkit: A Users Guide for Constructing, Presenting, Analyzing and Using
HIV Cascades in Vietnam. The contents of the guidelines are the
responsibility of the authors and do not necessarily reflect the views
of USAID or the United States Government.
FHI 360 Vietnam would like to thank to all our colleagues and partners
who provided invaluable inputs for this document.
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I.
Overview and Purpose
Although HIV may continue to be an important public heath threat for years to come, strong evidence in
support of the benefits of anti-retroviral therapy (ART) has ushered in an era in which we can envision an end
to the AIDS epidemic. Focusing outreach efforts on individuals at greatest risk; increasing uptake of HIV testing
and counseling (HTC) among key populations; facilitating early diagnosis of HIV infection and initiation on
ART; and retaining people living with HIV (PLHIV) on treatment are the hallmarks of a strong HIV response that
ultimately lowers viral suppression and achieves population-level impact.
To achieve ambitious AIDS-free goals, however, requires that implementers have tools that discern service
system gaps, help focus or prioritize programmatic interventions, and make the most strategic use of available
resources.
Why is the HIV CoPC cascade

important for Vietnam?
Watch this video
The continuum of HIV prevention to care (CoPC) cascade is a way to show, in visual form, the numbers of
individuals who are actually accessing CoPC services and receiving the services they need. At each step of the
continuum, the CoPC cascade illustrates engagement in an HIV service system. It powerfully identifies leaks
in the system, so that implementers at site, district, provincial or national levels can target limited resources
on effective interventions that improve the health of HIV positive individuals, lower the amount of virus in
vulnerable communities, and prevent new infections in the long term. Knowing where the drop-offs are most
pronounced is vital for knowing where, when and how to intervene to break the cycle of HIV transmission in
Vietnam.
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Purpose of this document

This user guide builds upon the World Health Organization (WHO) (2014) Metrics for Monitoring the Cascade
of HIV Testing, Care and Treatment Services in Asia and the Pacific. It is designed to help government and civil
society implementers construct, present, interpret and use HIV CoPC cascades in Vietnam with available data
and minimal technical assistance. The document outlines:
1. Recommended indicators for the standardized construction of HIV CoPC cascades in Vietnam
2. Simple steps to follow during the cascade generation process
3. Presentation guidelines for illustrating cascade performance by location, gender, population, program
and/or time; and
4. Important tips to help implementers effectively interpret and use HIV CoPC cascades
This guide has been designed for those who are new to developing and using HIV CoPC cascades. Two types of
cascades are highlighted in this introductory manual:
1. Periodic cascades that can be generated by implementers to illustrate programmatic gaps, progress
or achievements; and
2. Cross-sectional cascades that implementers can routinely develop to assess overall or aggregated
cascade performance in a designated area at any one point in time.
Advanced analytical, visualization, and data verification guidance for M&E professionals may be introduced
in guide updates, along with tips for developing more sophisticated cascades, including cohort HIV CoPC
cascades, and integrated health cascades (e.g. TB/HIV, methadone/ART).
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II.
Adaptation of the HIV CoPC Cascade in Vietnam
Common features of HIV cascades

HIV cascades are used all over the world, and are referred to by various names, including the HIV/AIDS care
continuum; the cascade of HIV care; and recently, the cascade of HIV testing, care and treatment services.
Click here to access the U.S.

Department of Health and
Human Services HIV/AIDS
Continuum website
HIV cascades commonly begin at HIV diagnosis and consist of six bars or steps that illustrate the continuum
of care (Figure 1).
Figure 1 | The continuum of care
1. HIV infected
2. HIV diagnosed
(Scroll over the bars for more information)

3. Linked to HIV care
4. Retained in
HIV care
5. On ART
6. Suppressed
viral load
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Key indicators, or metrics, are linked to each bar or step of HIV cascade. These indicators are used to generate a
visual representation of HIV service system performance. They help implementers to:

Obtain a snapshot of HIV service system performance
Present client engagement by gender or key population (as appropriate)
Identify loss of client engagement expressed as gaps, leakages or missed opportunities in the
continuum of HIV prevention to care
Prioritize actions to improve HIV service system performance
Illustrate programmatic progress or improvements over time
Use human, financial and programmatic resources in strategic ways
Adopt a public health approach that focuses on population-level impact
WHO (2014) has defined Metrics

for Monitoring the Cascade of
HIV Testing, Care and Treatment
Services in Asia and the Pacific.
Access the resource here.
Taken together, utilization of the cascade assists countries like Vietnam to provide the highest standard of care
that is feasible within available resources.
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Guiding Principles
Five key principles guide the construction and use of HIV CoPC cascades in Vietnam. Simply put, cascades
should be:
1. Simple to generate, by relying on a minimal set of core indicators that exist in the HIV service system
and are routinely collected as part of national reporting procedures.
2. Easy to use and interpret by a variety of implementers, with minimal outside technical assistance.
3. Adaptable, according to the data needs at program, site, provincial or national-levels.
4. Consistent, by using the same set of recommended indicators and clearly outlining the location, time
period and population represented in the analysis.
These four principles support the fifth one that utilization of the cascade
5. Fosters a culture of data use, that strives to continually improve the HIV service system in Vietnam.
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Vietnams HIV CoPC cascade

The HIV CoPC cascade has been adapted for Vietnams highly concentrated HIV epidemic to reflect the
importance of outreach efforts that identify key populations who are most vulnerable for acquiring or
transmitting HIV. Instead of six cascade bars, the Vietnam CoPC cascade has eight, depicted visually as follows
(Figure 2):
What each bar means
Get the Vietnam HIV CoPC

cascade here
Figure 2 | Vietnam HIV CoPC cascade
VL
Prioritize key
populations
approach
target
Populations
Identify
HIV positive
Individuals
Diagnose
PLHIV
Enrol
in care
Initiate
ART
Sustain
on ART
Suppress
viral loads
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The first three bars of the cascade focus on HIV prevention, or outreach. Cascade analysis across these bars
helps implementers better understand:

Who is being reached, and how many members of key populations are being reached, in HIV prevention
or outreach efforts
Who is testing for HIV and how many of these individuals are testing positive for the virus
Learn more about the enhanced

outreach approach here
The use of consistent unique identifier codes (UIC) in routine monitoring data efforts can improve the validity
of outreach data and enable program implementers to graph the progress of individuals through the cascade
of services. Figure 3 illustrates an HIV CoPC cascade that monitors overall cascade performance in outreach and
testing services without the application of UIC across one Vietnamese province. Figure 4 uses HIV prevention
UIC monitoring to track clients reached to testing, diagnosis, and to enrollment in care and treatment services
across nine provinces implementing USAID/SMART TAs enhanced outreach approach.
Figure 3 | HIV CoPC cascade (bars 1-4), Quang Ninh province, 2013
Figure 4 | HIV CoPC cascade (bars 2-5), Enhanced Outreach Approach,

9 provinces, May September 2014
10000
8000
9360
8000
6748
6357
7448
94%
Persons
Persons
6000
4000
6000
80%
4000
2000
19%
0
Identified KPs
Reached KPs
1218
Tested KPs
20%
248
Newly diagnosed
PLHIV
Source: Quang Ninh PAC, 6/2014
2000
3%
Reached KPs
Tested KPs
232
100%
Newly diagnosed
PLHIV
232
Enrolled in
Care
Source: USAID/SMART TA, Monthly Report, 2014
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A significant proportion of HIV positive individuals enter the cascade at HIV

diagnosis; in these cases, the Vietnam CoPC cascade can be modified to begin
at HIV diagnosis and extend to enrollment in care and initiation on ART, as
illustrated in Figure 5.
Figure 6 illustrates the same care and treatment cascade that now includes bar
7, or sustain on ART, which measures the number or proportion of PLHIV who
are registered at HIV care and treatment facilities 12 months after ART initiation.
Vietnam is unable to reliably collect population-level viral load data, as viral load
testing is not yet a routine part of the care and treatment monitoring system.
Figure 5 | HIV CoPC cascade (bars 4-6), Province A, January - December 2013
Figure 6 | HIV CoPC cascade (bars 4-7), Province A, January - December 2013
HIV CoPC Cascade of Province A by Gender, 1-12/2013

600
Persons
500
700
319
200
Female
Male
514
79%
400
85%
134
300
200
415
86%
356
88%
100
0
Newly diagnosed
PLHIV
500
488
158
Newly enrolled
in care
314
Newly initiated
ART
Source: Annual Report, PAC Province A, 2013
319
Female
600
Persons
700
HIV CoPC Cascade in Province A by Gender, 1-12/2013
200
Male
514
79%
400
488
158
85%
134
300
200
415
86%
356
88%
94%
314
100
0
Newly diagnosed Newly enrolled

PLHIV
in care
Newly initiated
ART
Sustained
on ART
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Detailed descriptions
for each CoPC cascade
indicator are found here
III. CoPC Cascade Metrics

1:1 rule
To ensure that CoPC cascades are based on consistent data sources, we follow a 1:1
rule. This means that a single, recommended indicator is used to designate each
bar of the cascade. Each of these indicators is (or will be) routinely collected in
Vietnam, as part of the national D28 or HIV INFO reporting systems.
Slightly different sets of metrics are associated with the two types of cascades that
can be commonly developed and used by program implementers:
1. Periodic cascades help implementers understand how their program is
performing. In particular, these cascades generate information on cascade
gaps and help implementers prioritize programmatic actions. These
cascades, when performed routinely, also assist implementers to track
programmatic quality improvement efforts. Core indicators for periodic

cascades outlined in Figure 7 focus on the number of clients who are
newly engaged in each step of the cascade over a specified time period.
2. Cross-sectional cascades assess overall cascade performance in a
designated area at any one point in time. Because Vietnam is currently
unable to reliably collect individual reach and testing figures, cross-sectional
cascades focus on care and treatment and include an initial cascade step
called Identify PLHIV. These cascades help implementers answer questions
such as How many people are enrolled in care?, or How many individuals
are on ART? Core indicators for cross-sectional cascades shown in Figure
8 aggregate program data across key cascade bars to provide the big
picture view of the HIV response and the major areas of cascade leakage at
the district, provincial or national levels.
Figure 7 | Recommended core numerical indicators for periodic cascades

Identify KP
Reach KP
Test KP
Diagnose PLHIV

Enroll in care
Initiate ART
Sustain on ART
Suppress viral
load
Enroll in care
NUMBER of new patients registered at HIV
outpatient clinics during the reporting period
Data Source:
D28 (adjusted)/facility ART register
UNAIDS, UNICEF, World Health Organization. Global AIDS response progress reporting 2014: Construction of core indicators for monitoring the 2011 United Nations political declaration on HIV and AIDS.
Geneva: UNAIDS; 2014 (http://www.unaids.org/en/media/unaids/contentassets/documents/document/2014/GARPR_2014_guidelines_en.pdf )
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Figure 8 | Recommended core numerical indicators for cross-sectional cascades
Identify PLHIV
Enroll in care
Initiate ART

Sustain on ART
Suppress viral load
UNAIDS, UNICEF, World Health Organization. Global AIDS response progress reporting 2014: Construction of core indicators for monitoring the 2011 United Nations political declaration on HIV and AIDS.
Geneva: UNAIDS; 2014 (http://www.unaids.org/en/media/unaids/contentassets/documents/document/2014/GARPR_2014_guidelines_en.pdf )
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Numbers first
All core indicators are first expressed as numbers. Implementers who prepare cascades using numerical core indicators will find it easy to convert the cascade data into
proportional or percentage figures, which are typically expressed as arrows between cascade bars.
Proportion indicators for periodic cascades are illustrated in Table 1. At each step of the periodic cascade, implementers can measure the uptake of services relative to
the previous stage. Here, the highlighted cascade step becomes the numerator and is divided against the value in the previous step (the denominator).
Table 1 | Calculating proportional or percentage data for periodic cascades
Cascade bars
Proportion/Percentage
Numerator/Denominator
Identify key populations

Reach key populations
PROPORTION of KPs reached by community

outreach workers during the reporting period
Numerator: NUMBER of KPs reached by community outreach workers during the reporting period
Reach key populations

Test key populations
Test key populations

Diagnose PLHIV
OR
Identify PLHIV
Diagnose PLHIV
Diagnose PLHIV
Enroll in care
Enroll in care
Initiate ART
Initiate ART
Sustain on ART
Suppress viral load
Denominator: NUMBER of persons in KP groups estimated by the end of the last reporting period
Numerator: NUMBER of KPs who received test results and post-test counseling during the reporting
period
PROPORTION of KPs reached by community

outreach workers who received test results and
post-test counseling during the reporting period Denominator: NUMBER of KPs reached by community outreach workers during the reporting period
Numerator: NUMBER of KPs who received HIV+ test results and post-test counseling during the
PROPORTION of KPs who received HIV+ test
reporting period
results and post-test counseling during the
Denominator: NUMBER of KPs who received test results and post-test counseling during the reporting
reporting period
period
OR
OR
PROPORTION of newly diagnosed PLHIV
Numerator: NUMBER of newly diagnosed PLHIV reported from HIV INFO during the reporting period
reported from HIV INFO during the reporting
Denominator: Number of KPs who received test results and post-test counseling during the reporting
period
period
Numerator: NUMBER of new patients registered at HIV outpatient clinics during the reporting period
PROPORTION of new patients registered at HIV
Denominator: NUMBER of newly diagnosed PLHIV reported from HIV INFO during the reporting
outpatient clinics during the reporting period
period
Numerator: NUMBER of PLHIV with advanced HIV infection who are newly enrolled on ART during the
PROPORTION of PLHIV with advanced HIV
reporting period
infection who are newly enrolled on ART during
Denominator: NUMBER of new patients registered at HIV outpatient clinics during the reporting
the reporting period
period
Numerator: NUMBER of PLHIV known to be alive and on treatment 12 months after initiation of ART
PROPORTION of PLHIV known to be alive and
on treatment 12 months after initiation of ART
Denominator: NUMBER of PLHIV who initiated ART 12 to 24 months prior to the reporting period
PROPORTION of PLHIV currently on ARV
treatment who have a viral load less than
1000 per ml of blood
Not currently applicable
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Table 2 outlines proportion indicators for cross-sectional cascades. In cross-sectional cascades, two cascade steps are highlighted: (1) enroll in care and (2) initiate ART.
The denominator for both cascade steps is the first cascade stage: Identify PLHIV. This allows implementers to calculate the total numbers of PLHIV who are accessing
care and treatment services at a particular point of time.
Table 2 | Calculating proportional or percentage data for cross-sectional cascades
Cascade bars
Proportion/Percentage
Numerator/Denominator
Enroll in care
Identify PLHIV
PROPORTION of patients who are currently

registered at HIV outpatient clinics by the end
of the reporting period
Numerator: NUMBER of patients CURRENTLY registered at HIV outpatient clinics by the end of the
reporting period
Initiate ART
Identify PLHIV
PROPORTION of PLHIV with advanced HIV

infection who are currently enrolled on ART by
the end of the reporting period
Denominator: Total NUMBER of PLHIV reported from HIV INFO by the end of the reporting period
Numerator: NUMBER of PLHIV with advanced HIV infection who are CURRENTLY enrolled on ART
by the end of the reporting period
Denominator: NUMBER of patients CURRENTLY registered at HIV outpatient clinics by the end of the
reporting period
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Data limitations
Like any tool, there are limitations associated with the utility and application of the HIV CoPC cascade.
Implementers must be cognizant that:
1. The usefulness of the CoPC cascade is heavily influenced by the quality of available data.
Routine data quality assurance procedures are important for ensuring accurate reporting. Its crucial
for implementers to know the source of data and how data are reported when calculating the
indicators. Missing information such as the numbers of PLHIV loss to follow up or dead from AIDS
can skew bar totals and under- or overestimate the impact of a CoPC program. Over-reporting
counting outreach contacts instead of outreach individuals for instance will accentuate the size
of the reach-testing gap. The lack of disaggregated HIV testing figures for key populations means
that implementers will need to adjust the data during the cascade generation process.

Its important to note that individuals enter and/or leave the continuum of HIV services at any point
in the cascade and, as a consequence, it becomes difficult to infer causal relationships between
cascade bars. The utilization of coordinated UIC systems are particularly helpful for monitoring the
linkages between services, reducing episodes of double counting, and tracking individuals as they
transition from services and locations.
2. Consistency is critical. When implementers do not use core indicators in the construction
of cascades and when they do not clearly identify geographic location, time, data source, or
population it limits the usefulness of the cascade and makes it difficult for others to reliably
assess service performance.
3. The cascade is an important but not sole tool in HIV service planning and quality
improvement efforts. It should be used together with other programmatic and strategic
information/M&E tools such as service mapping, quality improvement monitoring, epidemic
modeling, and gender/policy/service access assessments to better understand and program
for the response.
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IV. Building a CoPC cascade

Preparatory steps
Building a CoPC cascade starts with 6 simple steps:
1. What? Identify the kind of cascade to be used. Will focus be placed on assessing cascade gaps and prioritizing/
tracking programmatic actions (periodic cascade)? Is emphasis given on calculating the total numbers of
individuals served in care and treatment and assessing overall programmatic progress (cross-sectional cascade)?
Knowing what cascade to use is a critical first step in cascade construction.
USAID/SMART TA has created

HIV CoPC cascade data collection
tools to facilitate cascade
preparation in Vietnam. Get these
resources here
2. Where? Distinguish the geographic area of focus or scope. Is it the national HIV system? The provincial or
district response? A particular program? One facility? Knowing the focus of a cascade will help implementers
identify key data needs and steer them towards appropriate data sources.
3. Which service area will be emphasized? Will focus be on the full CoPC? Outreach? Care and treatment? Knowing the CoPC technical focus will assist
implementers to distinguish which cascade bars will be examined.
4. Who? Identify the population. Will data disaggregation be by key population or gender? Or will total population figures be used? Because women/men and
key population sub-groups may have unique CoPC service access, acceptability or utilization issues, it is recommended that implementers use disaggregated
data whenever possible.
5. When? Plot the time period, clearly specifying the start and end dates (e.g. month/year). Ensure that the time period reflects an official reporting cycle, such
as the end of a month, quarter, semi-annual or annual episode.
6. How? Distinguish presentation format. Will a cascade graph be used, or another representational style, such as a dashboard or trend graph.
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Data collection guidance and considerations

All data used in the preparation of HIV CoPC cascades should come from official reports, particularly reports submitted as part of the D28 M&E reporting requirements.
Weve added important data collection considerations for each step of the CoPC cascade below:
1. Identifying key populations Its critical that implementers use size estimation figures that have been officially vetted, either through provincial consensus
consultations or via national modeling exercises. D28 forms 2 (quarter period) and 4 (annual period) provide this information for the provincial and district
levels.
2. Reaching key populations Outreach figures should use individuals reached not contacts as the designated unit of analysis. Whenever possible, data
should be disaggregated by KP sub-category and gender.
3. Testing key populations HIV testing and counseling data in Vietnam records the number of tests, rather than the number of individuals who test. This means
that one individual may test for HIV multiple times at the same facility during a specific reporting period. The data from D28 forms 10 (quarter period) or 15
(annual period) must therefore be adjusted to exclude repeated positive tests; we provide guidance on how to do so in the following section.
4. Identifying PLHIV HIV INFO records the total number of PLHIV reported in districts and provinces within a specified reporting period.
5. Recording newly diagnosed PLHIV HIV INFO documents the number of newly diagnosed PLHIV within a specified reporting period.
6. Enrolling PLHIV in care Using the facility ART (and pre-ART) registers, it is important for implementers preparing periodic cascades to collect data only for the
number of new patients registered at HIV outpatient clinics during the reporting period. Implementers preparing cross-sectional cascades can access aggregated
data in D28 forms 12 (annual period) or 7 (quarterly period).
7. Initiating ART Implementers preparing periodic cascades must distinguish the number of PLHIV who newly initiate ART using the facility ART register or D28
forms 12 (annual period) or 7 (quarterly period). Those preparing cross-sectional cascades can also gather cumulative data using the same D28 forms.
8. Sustaining ART The last bar of the cascade requires implementers to collect data from the previous 12-month period. This figure includes all adult and
children patients who are alive and on ART 12 months after initiation of treatment as reported in facility ART registers or D28 form 13 (annual period) or 8
(quarterly period).
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Adjusting data
In Vietnam, HIV testing and counseling data records the number of tests conducted,
rather than the number of individuals who test for HIV. This means that the data
must be adjusted in order to estimate a true number of KPs who test, with repeat
testers which can constitute, on average, 25% of total tests subtracted from
the totals. Implementers can use the following formula to adjust the data for the
number of key populations tested, and for the number of key populations who test
HIV positive (which may be included within this column bar):

Number of KP clients who test for HIV = (Number of reported tests)

x (Proportion of clients who tested that are KPs (IDUs, FSWs, MSM)) x ( 1Proportion of clients who retested among clients who are KPs)
Number of KP clients who test positive for HIV = (Number of reported

positive tests) x (Proportion of clients who are KP among clients who are
positive for HIV) x (1- Proportion of KP clients who retested among clients
who are positive for HIV)
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V.
Presenting a CoPC cascade
General presentation guidelines
2. Vertical axis. The vertical axis should be displayed as numbers (either

hundreds, thousands or higher, as applicable) with the title persons or
clients.
3. Horizontal axis. We recommend keeping the cascade bar titles consistent
with the ones described in the guide; using different cascade bar terms
can be confusing and can make it difficult to compare cascade data over
time and place.
4. Designating cascade column values (top). Putting numerical values (in
numbers) at the top of each relevant column makes it easy for others to
interpret the cascade and to use the information for programmatic quality
improvement.
Figure 8 | CoPC cascade presentation guidelines

2500
2000
Persons
1. Title. All CoPC cascades should have a title that illustrates (a) geographic
location or scope; (c) population focus (as applicable); and (d) targeted
time period, with month/year if possible.
2000
1500
1500
1100
1000
500
0
75%
Identified
Individuals
73%
8%
88
91%
80
75
85%
Initinated
ART
Sustained
on ART
94%
Reached
Tested
Diagnosed Enrolled in
Individuals individuals
PLHIV
Care
Source: Annual Report, PAC of Province D, 2013
5. Indicating proportions. Arrows linking cascade bars are labeled with

percentages that indicate the proportion of clients moving across relevant
steps of the CoPC continuum.
6. Indicating data source(s). Whenever possible, CoPC cascades should
have the relevant data sources listed on the bottom of the graph.
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Stacking cascade bars

In some cases, implementers may want to disaggregate cascade data by:
Gender, by showing the differences between men and women as they move
Key population, by distinguishing the proportion of MSM, FSWs or PWID
through the CoPC
reached and tested for HIV
Figure 9 | HIV CoPC Cascade of Province A by Gender, 1-12/2013
Figure 10 | HIV CoPC Cascade of People Who Inject Drugs in Province E, 2013
Persons
300000
Female
258524
250000
65558
111% 219163
Persons
200000
Male
2000
3000
4000
5000
6000
7000
8000
9000
8000
Tested Individuals
9%
72543
76%
150000
1000
750
Diagnosed PLHIV
71%
100000
85532
192966
146620
42%
50000
38%
Identified PLHIV
Diagnosed PLHIV
84457
30255
99%
55277
99%
Enrolled in Care
Enrolled in Care
29898
54559
530
85%
Ininiated ART
450
Initiated ART
Source: Annual Report, PAC of Province E, 2013
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KPs who test positive for HIV, as compared to the total who tested
Service sites, by showing which sites contribute to cascade bar totals
Figure 11 | HIV CoPC Cascade of PWID and Others in Province B, 2013
Figure 12 | HIV Care and Treatment Cascade of Site A compared to other Sites

in Province C, 2013
1400
5000
KPs
Others
4500
1200
434
3000
600
200
708
3500
5%
800
400
Other sites
4000
Persons
Persons
1000
Site A
2500
2000
4015
97%
97%
690
664
1500
750
4%
KPs: 48%
Others: 67%
21
30
0
Tested individuals Diagnosed PLHIV
10
KPs: 70%
Others: 75%
20
Enrolled in Care
1000
7
15
Initiated ART
Source: Annual Report, PAC Province B, 2013
40%
500
0
Diagnosed PLHIV
1615
97%
Enrolled in Care
1566
Initiated ART
Source: Annual Report, PAC of Province C, 2013
Adding complexity to simple cascades is possible, if the data is available. Implementers should be sure to label stacked bars with relevant information and to
designate data sources whenever possible.
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Graphic presentation styles

There are many ways to show cascade data:
Figure 13 | HIV Prevention Cascade for Enhanced Outreach Approach

in 9 Provinces, May-September 2014
Figure 14 | HIV Care and Treatment Cascade of Site A compared to other Sites

in Province C, 2013
10000
5000
9360
4500
8000
4000
6000
4000
708
3000
2500
2000
4015
97%
97%
690
1500
2000
1000
3%
Reached KPs
Tested KPs
Other sites
3500
80%
Persons
Persons
7448
Site A
232
100%
Newly diagnosed
PLHIV
232
Enrolled in
Care
40%
500
0
Diagnosed PLHIV
97%
1615
Enrolled in Care
664
1566
Initiated ART
Source: Annual Report, PAC of Province C, 2013
1. Cascade graphs. Our preferred style of presentation, cascade graphs visually display leaks in the HIV service system, where individuals may not be accessing
CoPC services and receiving the services they need.
2. Indicator dashboards. This data visualization tool can provide implementers with an at a glance listing of key cascade indicators. Dashboards show
recent program performance and actionable information. While dashboards do not track individuals as they progress through the CoPC, they do provide
a cross-representational representation of different groups of individuals at different stages of the cascade.
3. Trend graphs. Trend graphs are particularly useful when implementers assess progress or improvements over time of particular indicators.
A cascade graph is illustrated in Figures 13 and 14; indicator dashboards and trend graphs are shown in Figure 15.
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Figure 15 | HIV CoPC Cascade of Enhanced Outreach Approach, May October, 2014
14000
#2.PROPORTION OF SUB-POPULATION BY KPS

REACHED (CUMULATIVE)
#3. REACH: NUMBER OF KEY POPULATION REACHED BY MONTH

4000
13159
Sex partners, 15%
12000
10729
3799
3500
FSW, 39%
3000
10000
8000
Clients
Clients
2500
6000
2000
PWID, 29%
82%
1000
MSM/TG, 17%
3%
Reach KPs
Test KPs
321
101%
Diagnose PLHIV
325
Enroll in Care
Percentages
70%
67%
72%
5%
77%
50%
40%
30%
0%
4%
3.42%
3%
2.63%
2.39%
2.71%
Months
%KPsTested
Aug-14
Sep-14
Oct-14
HIV Tested Target 70%
May-14
180
95%
Jun-14
Jul-14
Aug-14
Sep-14
Months
%HIV+
HIV Threshold 6%
104%
160
93
140
100
56
65
80
60
36
16
27
37
May-14
Jun-14
89
62
Jul-14
# Enroll in Care
#Diagnose PLHIV
0%
200
106%
59
40%
1%
Jul-14
59%
60%
0%
Jun-14
Oct14
120
80%
20%
2%
May-14
Sep14
4.13%
20%
10%
97%
100%
4.30%
60%
Aug14
Months
123%
120%
86%
Percentages
80%
85%
Jul14
140%
Percentages
85%
Jun14
#6. PERCENTAGE OF PLHIV ENROLLED IN CARE BY MONTH*
7%
6%
90%
May14
#5. DIAGNOSE: PERCENTAGE OF NEWLY REPORTED

HIV INFECTION AGAINST 6% THRESHOLD BY MONTH
#4: TEST: PERCENTAGE OF REACHED KEY POPULATIONS

TESTED BY MONTH
100%
933
500
2000
0
1939
1511
1500
4000
2608
2369
Clients
#1. CASCADE PERFORMANCE (CUMULATIVE)
53
Aug-14
Months
40
53
20
Sep-14
% PLHIV in Care
Oct-14
Average of Enroll Target 85
Oct-14
#7. NUMBER RE-ENGAGED in CARE AND TREATMENT

25
23
23
Sep-14
Oct-14
Number
20
15
12
10
5
0
10
9
4
May-14
Jun-14
Jul-14
Aug-14
Months
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VI. Interpreting a CoPC cascade

Interpretation tips
The real value of CoPC cascades lies in their use as programmatic assessment and quality improvement tools. When reviewing cascade data, implementers should
ask the following questions as they begin the process of interpretation and utilization:
1. Where are the leaks? While there may be leaks throughout the cascade, some areas may be more pronounced, or more important to address, than others.
Often, key leaks in the cascade occur from the reach test, and from the diagnosis enrollment phases of the cascade. Deciding where to focus quality
improvement efforts is a critical step in interpreting cascade data.
2. Who is most affected by the leak(s)? Is the data disaggregated by gender and/or KP subcategory? If so, are there differences between groups and their
service access, uptake or retention?
3. Why are there leaks? Implementers should examine, in collaboration with service providers, KP clients, and other key stakeholders, the reasons behind
cascade leaks. Reasons can include:
Client access and uptake barriers. Do clients know and believe in the benefits of the service(s)? Are service locations accessible, affordable,
and convenient?
Structural barriers. Does the legal and policy environment facilitate or impede client access and uptake of services?
Data quality issues. Do data quality issues compound cascade gaps, or minimize cascade leakages?
4. How do we best address the leak(s)? While cascade guide updates will focus on the practice of cascade quality improvement action planning and course
corrections, implementers can now use the cascade as a starting point for brainstorming about solutions. One of the important strengths in using the
cascade is that it can not only identify where the leak is and who is most affected, it can also lead to tailored interventions that will be most effective in
addressing and closing the leaks. Examples of common leaks and relevant solutions include:
Low service coverage of KPs: Solutions may include moving services to locations closer to the KPs, extending opening/closing times, reducing fees,
integrating services, training providers to create a more friendly environment for clients being served, etc.
Outdated or no specific policy, may require the updating of policies and standard operating procedures, issuing directives and decrees, etc.
Limited clientele, may require demand creation strategies, performance-based incentives, greater confidentiality, transportation support, etc.
It is important for implementers to brainstorm on a variety of possible solutions, and to work in close collaboration with KP clients, HIV service providers, and policy
makers, as they develop strategies for improving cascade performance.
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VII. Supporting others to generate, present and use simple HIV CoPC cascades
Key resources
USAID/SMART TA has prepared training materials for individuals who would like to support others to prepare and present CoPC cascades. Click here to access all
resource materials.
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VIII. Summary
This introductory guide has been designed to help government and civil society implementers construct, present, interpret and use HIV CoPC cascades in Vietnam
with available data and minimal technical assistance.
The cascade approach identifies leaks in the system, targeting resources on interventions that diagnose people with HIV, quickly initiate ARV treatment, and
sustain PLHIV in care. Using the cascade - in every facility, commune, district and province will help Vietnam monitor HIV service system performance and focus
its remaining human, financial and programmatic resources on the ultimate aim of the HIV response: viral suppression. Knowing where the drop-offs are most
pronounced can assist decision makers and service providers to implement system improvements and service enhancements that make the greatest impact for
individuals, communities and Vietnamese society.
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HIV CASCADE TOOLKIT:

for constructing, presenting , interpreting

Purpose of this document

II. Adaptation of the HIV CoPC Cascade in Vietnam 7

Vietnams HIV CoPC cascade

CoPC Cascade Metrics 13

Building a CoPC cascade 18

Data collection guidance and considerations

Presenting a CoPC cascade 21

General presentation guidelines

Stacking cascade bars

Graphic presentation styles

Interpreting a CoPC cascade 26

Acquired Immune Deficiency Syndrome

Overview and Purpose

Why is the HIV CoPC cascade

Purpose of this document

Adaptation of the HIV CoPC Cascade in Vietnam

Common features of HIV cascades

Click here to access the U.S.

Figure 1 | The continuum of care

(Scroll over the bars for more information)

Obtain a snapshot of HIV service system performance

Present client engagement by gender or key population (as appropriate)

Prioritize actions to improve HIV service system performance

Illustrate programmatic progress or improvements over time

Use human, financial and programmatic resources in strategic ways

Adopt a public health approach that focuses on population-level impact

WHO (2014) has defined Metrics

Vietnams HIV CoPC cascade

What each bar means

Get the Vietnam HIV CoPC

Figure 2 | Vietnam HIV CoPC cascade

(Scroll over the bars for more information)

Learn more about the enhanced

Figure 4 | HIV CoPC cascade (bars 2-5), Enhanced Outreach Approach,

Source: USAID/SMART TA, Monthly Report, 2014

A significant proportion of HIV positive individuals enter the cascade at HIV

HIV CoPC Cascade of Province A by Gender, 1-12/2013

Source: Annual Report, PAC Province A, 2013

HIV CoPC Cascade in Province A by Gender, 1-12/2013

Newly diagnosed Newly enrolled

Source: Annual Report, PAC Province A, 2013

III. CoPC Cascade Metrics

programmatic quality improvement efforts. Core indicators for periodic

Figure 7 | Recommended core numerical indicators for periodic cascades

(Scroll over the bars for more information)

Figure 8 | Recommended core numerical indicators for cross-sectional cascades

(Scroll over the bars for more information)

Suppress viral load

Identify key populations

PROPORTION of KPs reached by community

Reach key populations

Test key populations

PROPORTION of KPs reached by community

Not currently applicable

PROPORTION of patients who are currently

PROPORTION of PLHIV with advanced HIV

IV. Building a CoPC cascade

USAID/SMART TA has created

Data collection guidance and considerations

Number of KP clients who test for HIV = (Number of reported tests)

Number of KP clients who test positive for HIV = (Number of reported